You are 43, your cycle has been all over the place for a few months, you sleep poorly and you have a shorter fuse than you recognise in yourself. Your GP says your blood values look fine. Yet you feel something is shifting. Sound familiar? This is exactly how perimenopause often announces itself.
My position: perimenopause is the most missed life stage in women's health. Not because it is rare, but because it hides behind complaints we attribute to stress, busyness or age. Below you read what happens, which signs belong to it, at what age it starts, when a blood test adds value and what you can do yourself.
What is perimenopause?
Perimenopause is the transition phase toward menopause, the moment you have not had a period for a year. In this phase your ovaries produce increasingly variable amounts of estrogen and progesterone. Those fluctuations cause the complaints.
The treacherous part is the unpredictability. One month you feel fine, the next you sleep poorly and feel irritable. Because you are still menstruating, you often do not link it to menopause. Read also about the five phases of menopause, from perimenopause to postmenopause.
What are the first signs of perimenopause?
The first signs often revolve around your cycle and your sleep, even before hot flushes appear. Not every woman has everything, and the order differs. Often a combination of complaints is the first real clue.
- A changing cycle: shorter, longer or more irregular than you are used to
- Sleeping worse or lying awake at night
- Mood swings, irritability or more anxiety
- Fatigue that does not match your sleep
- Palpitations, sometimes without a clear cause
- A foggy head or trouble concentrating
Many of these complaints also fit stress, an underactive thyroid or iron deficiency. That is why they are so easy to miss. Unsure whether it is menopause or something else? Read our article on menopause or burnout.
At what age does perimenopause start?
Perimenopause starts for most women between 40 and 45, but it can be earlier. The average age of menopause in the Netherlands is around 51, and perimenopause precedes it by an average of four to eight years.
If it starts before you are 40, it is worth discussing with a doctor. It may indicate an early menopause, which according to the Dutch GP guideline (NHG) and the NVOG (Dutch Society for Obstetrics and Gynaecology) needs extra attention because of long-term effects on your bones and heart. Read also our article on the average age of menopause.
Which hormones change, and in what order?
Menopause is not an on-switch but a spectrum. The hormones shift in a rough order, though it differs per woman. The table below gives an overview of what usually changes and when measuring makes sense.
| Hormone | What happens | Best time to measure |
|---|---|---|
| Progesterone | Often falls first, as ovulation becomes more irregular | Luteal phase, around day 19-22 in a 28-day cycle |
| FSH | Rises gradually, but fluctuates strongly month to month | Cycle day 2-5, if you still menstruate |
| Estradiol (E2) | Erratic peaks and dips, falls structurally after menopause | Cycle day 2-5, or at a moment of symptoms |
| LH | Rises along with FSH, often less pronounced | Together with FSH, cycle day 2-5 |
Important to remember: in perimenopause your hormones fluctuate by their nature. A single measurement is a starting point, not a diagnosis. The pattern over two or three measurements tells you more than a single result.
Track your cycle and complaints
Because a single blood value says little in this phase, your own account is often the most valuable piece of information you bring to your GP. The Dutch GP guideline on menopause (NHG) places your story and your cycle at the centre when assessing menopausal complaints. The more concrete you make that story, the more targeted the conversation.
What is worth tracking for a few months:
- The length of your cycle and how it shifts, shorter or longer than you are used to
- How heavy your menstruation is and whether unusual bleeding occurs
- When hot flushes, bad nights or mood swings occur, and how often
- What you notice around ovulation and in the week before your period
A simple app or a note on your phone is enough. After two to three months you often see a pattern that you do not notice in single weeks. That pattern, combined with a possible blood test, gives your doctor more to go on than a snapshot. It also helps you: you start to recognise the fluctuations instead of being caught off guard by them each time.
Can you test for perimenopause?
A single blood value does not establish perimenopause, precisely because your hormones fluctuate. Still, a measurement can help, especially to rule out other causes or in case of an early onset. FSH rises gradually in this phase, but can differ month to month.
It is often worthwhile to look at your thyroid and iron alongside your hormones, because they can cause the same complaints. The Menopause Check looks at the hormones that belong to this phase. If you want to look more broadly at your hormonal balance, the Women's Hormones panel can bring more values into view. Read also which hormones to test around menopause.
Why do the hormones fluctuate so erratically?
The erratic nature is what makes perimenopause so confusing, and it has an explanation. In your fertile years an egg matures each month, and the accompanying follicle neatly produces estrogen and then progesterone. As the number of follicles declines, that process becomes irregular. One month a follicle still matures, the next month not, or only partly.
That explains why your estradiol does not fall calmly, but can swing back and forth. Sometimes, in an attempt to mature an egg anyway, your body temporarily makes extra estrogen, resulting in a peak. A week later that same estradiol can have dropped deeply. Those peaks and dips, not just the low level, cause much of the trouble. Progesterone meanwhile is often already structurally low, because there are fewer ovulations. The ratio between estrogen and progesterone therefore falls out of balance, even when your estrogen is still normal or even high at a given moment.
For measuring this means two things. One: the timing in your cycle matters. Two: a single measurement captures only a moment of a moving picture. That is not a shortcoming of the test, but the nature of this life stage.
Is it menopause, or something else after all?
Many perimenopause complaints are not unique. Fatigue, low mood, palpitations and a foggy head also fit an underactive thyroid, iron deficiency or prolonged stress. Precisely because the complaints overlap, it is worth looking more broadly than just your sex hormones when in doubt. For the palpitations themselves, read when palpitations in menopause call for testing.
| Complaint | Fits menopause | Could also point to |
|---|---|---|
| Fatigue, feeling cold | Yes | Underactive thyroid (TSH), iron deficiency (ferritin) |
| Palpitations | Yes | Thyroid, anaemia, anxiety |
| Low mood, irritability | Yes | Stress, depression, thyroid |
| Foggy head, poor concentration | Yes | Sleep deprivation, stress, vitamin B12 deficiency (B12) |
That is why it can be worthwhile to include your thyroid and iron when you have your hormones tested. This prevents you from overlooking a treatable cause by attributing everything to menopause. If you are torn between menopause and exhaustion, read our article on menopause or burnout.
Which complaints fit which phase?
It can be hard to work out where you stand. A rough sketch per phase helps you recognise your own pattern.
- Early perimenopause: your cycle becomes shorter or more irregular, progesterone falls, you sometimes notice PMS-like complaints, FSH may still be normal.
- Late perimenopause: longer periods without menstruation, clearly raised FSH, falling estradiol with fluctuations, hot flushes and sleep problems.
- Menopause: twelve months without a period, FSH structurally raised, estradiol structurally low.
- Postmenopause: stable low hormone levels, complaints gradually ease for most. Read more about what happens after menopause.
What can you do yourself?
Perimenopause is a natural phase, not an illness, but the complaints are often well manageable. Attention to sleep, movement and stress makes a difference for many women. It does not replace medical treatment, but it helps you keep a grip.
- Sleep: keep a fixed sleep rhythm, including at the weekend, and ensure a cool, dark bedroom. That helps especially if hot flushes wake you at night.
- Movement: move regularly, with attention to strength and your bones. Weight-bearing movement such as walking, stairs and strength training supports your bone density, which falls faster after menopause.
- Nutrition: the Dutch Nutrition Centre (Voedingscentrum) advises a varied diet with enough protein and calcium, and for women aged 50 and over extra vitamin D on the advice of the Gezondheidsraad.
- Stimulants: watch alcohol and caffeine, which can disrupt hot flushes and sleep. Many women notice that an evening glass of wine makes the night more restless.
- Support: talking to others in the same phase helps. Stichting Menopauze offers reliable public information and recognition.
These lifestyle steps are not a substitute for medical care, but they give you a grip and can ease complaints. What makes the biggest difference differs per woman. Give a change a few weeks before you judge whether it works.
Specific complaints sometimes deserve their own approach. If you sleep poorly, read our article on poor sleep in menopause. If you gain weight unexplainably, read about weight gain in menopause. If your complaints persist or interfere with daily life, discuss the options with your GP. Read also about hormone therapy in menopause, which according to the NHG can be an effective option for bothersome complaints after a careful weighing of pros and cons.
When to see your GP?
See your GP if your complaints affect your daily life, if they start before you are 40, or in case of unusual bleeding. The Dutch GP guideline on menopause (NHG) and Thuisarts.nl describe how GPs in the Netherlands view menopausal complaints. Stichting Menopauze also offers reliable public information if you want to read further.
With Lunara you have your blood drawn without a referral at a location near you, and each value in your result receives an assessment from a BIG-registered doctor. So you know what your values may mean in your situation and whether a next step makes sense. A blood test does not replace a conversation with your GP, but it does give you a well-founded starting point.
Frequently asked questions
How long does perimenopause last?
On average four to eight years, but it varies greatly per woman. The phase ends at menopause, the moment you have not had a period for a year.
Can you have perimenopause and still menstruate?
Yes, that is actually characteristic. In perimenopause you still menstruate, but your cycle becomes more irregular. Only after a year without a period do we speak of menopause.
Does a hormone test give certainty?
Not always, because your hormones fluctuate. A test can help to rule out other causes or in case of an early onset. Discuss the result with a doctor.
I am under 40 and have menopausal complaints. What now?
Complaints before 40 can point to an early menopause. According to the NVOG this needs extra attention because of long-term effects on your bones and heart. Discuss this with your GP; a hormone test can be part of the work-up. We set out the symptoms of early menopause separately.
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